Engaging consumers in changing health behaviors

Beyond words

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In order to positively impact workforce health and reduce costs, employers must move their health programs beyond words to a state of consumer engagement and action. This article summarizes relevant concepts and findings from the fields of psychology, decision research, and social marketing and identifies best practices in developing consumer engagement. Employers can utilize this information when creating health care programs and tools to control costs and improve workforce health and productivity.

Most employers, desperate to reduce healthcare costs1, are adopting a variety of health care “consumerism” tactics, including:

• High deductible insurance programs coupled with tax effective savings accounts

• Wellness or “health promotion” programs that encourage and support healthy lifestyles

• Disease and case management programs that improve the care of participants

• Decision support resources, delivered via Web portals, 24-hour nurse lines and other channels, to empower consumers to make more informed health care decisions

• Meaningful incentive programs that reward desirable behaviors and healthy lifestyles

These initiatives succeed if — and only if — they stimulate real and lasting behavior changes in employees and their dependents. That’s easier said than done.

Employers are beginning to recognize that communication alone does not guarantee success. Although effective communication is a critical first step, on its own, it will not bring about the behavioral change necessary for consumerism to reduce costs.

Many employers have moved beyond communication to educating individuals about the need for change and the benefits of changing. However education will not stimulate action if employees are not also empowered with the tools and information necessary to facilitate better choices. And even then, educated employees empowered with useful tools may choose not to use them. These programs must move beyond communication, beyond education, and beyond empowerment, to a state of effective engagement.

Engagement is the link that connects education to action — motivating individuals beyond a state of awareness to adopt and maintain new behaviors and healthy lifestyles.

The Steps to Behavioral Change

Educate Empower EngageCommunicate

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What drives engagement?Much of the current literature on consumer health care engagement is directed at employers eager to motivate employees and their families to improve personal health care behaviors. No one questions the conventional wisdom of providing individuals with reliable and objective information and targeted messages, utilizing incentive rewards, and obtaining senior management support for wellness and other consumer initiatives. Somehow, though, employers that take one or all of these steps don’t always end up with engaged consumers. Even when information is made available to individuals, they do not necessarily use it to make informed health care decisions. A recent poll, for instance, shows that millions of Americans have seen ratings of hospitals, health plans and physicians, but less than one percent have used these ratings to make decisions to change plans, doctors or hospitals2. The reason for this apparent lack of engagement is likely multifaceted.

Engagement (in this context) results from a complex interaction of two primary elements:

1. The employer’s ability to create the conditions that will promote employee engagement, and

2. The employee’s unique psychosocial make-up

Both of these elements must be understood and addressed before employers’ engagement efforts can succeed. Our search for a deeper understanding of engagement takes us to three disciplines — psychology, decision theory, and social marketing — and, ultimately, to the best practices that employers can utilize to help create an environment that fosters health care engagement.

Health is its own reward — but a little cash helps tooArguably, the strongest motivators for employee engagement should be the economic and health benefits that naturally result from more informed, healthier behaviors. But unfortunately, saving money on health costs, and living a longer, healthier life, are not always sufficient motivators for lasting behavioral change in much of today’s population.

To stimulate engagement, some employers offer financial rewards to those employees who initiate positive behavioral changes. Economic incentives that speak to our pocketbooks can be an effective first step in capturing employee attention and initial behavioral change. But lasting lifestyle changes necessitate a higher level of motivation than can be achieved through short-term financial incentives — they require true engagement, a long-term commitment and passion, that lives in our minds and our hearts.

Discipline 1: PsychologyPsychology obviously plays a key role in our decision to make behavioral changes and to act upon those decisions. But what really goes on inside our heads as we weigh our options? And how can a better understanding of this process support better decision-making?

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Contemporary theories of health behavior are based on cognitive-behavioral models. Three key concepts underlie these models3:

1. Behavior is mediated by cognitions. In other words, what people know and think affects how they act.

2. Knowledge is necessary for, but not sufficient to produce, most behavioral changes. Unlike reflexive conditioning (epitomized by Pavlov’s salivating dogs), cognitive behavioral theories rely on helping an individual understand the thought processes that lead to behavioral change. (That’s where the “cognitive” part comes in.

3. Perceptions, motivations, skills and the social environment are key influences on our behavior. Changing behavior requires more than just cognitive information. Many other factors come into play to impact our actions.

Psychologists have developed numerous models of how behavioral change occurs. This section summarizes four popular models and explores how they can deepen our understanding of behavioral change to improve the design of employee health programs.

Stages of Change (Transtheoretical Model): This model4, first developed by Prochaska in 1979, is probably the best-known cognitive-behavioral model within the employer community. The Stages of Change model provides a framework for explaining how behavioral change occurs. According to this model, there are five stages of change:

Table 1: Objectively integrate emerging core competencies

Stage number Stage name Characterized by:

1 Pre-contemplationNot thinking about changing behavior

2 ContemplationThinking about changing behavior in the near future

3 PreparationMaking a plan to change behavior

4 ActionImplementing the plan to change behavior

5 MaintenanceSustaining new behaviors and working on preventing relapse

In the Stages of Change model, behavioral change is viewed as a process in which individuals are at various stages of readiness to change. The stages are not linear. People can enter and exit stages at any point, and some people may repeat a stage several times.

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Our programs must move beyond communication, beyond education, and beyond empowerment, to a state of effective engagement. Engagement is the link that connects education to action — motivating individuals beyond a state of awareness to adopt and maintain new behaviors and healthy lifestyles.

Employers and vendor programs seeking to increase employee engagement in wellness and health promotion initiatives often use this model. Its key tenet implies that employees are not all “in the same place” with regard to their willingness and readiness to change, and so must be treated differently in order to impact their behaviors. The most successful applications attempt to first engage each individual in an assessment of their personal stage of change before recommending behavior modification programs.

Motivational Interviewing (MI): Miller and Rollnick originally developed Motivational Interviewing (MI)5 as a complementary process to the Stages of Change model. MI is a style of patient practitioner communication that is specifically designed to resolve ambivalence and build motivation for behavioral change. MI is based on the theory that individuals will ignore or dismiss information on “how to change” if they are not ready or willing to change.

MI principles suggest approaching each individual without judgment, assisting them to feel empowered to make behavioral changes by identifying pros and cons to behavioral change and understanding what maintains unhealthy behaviors. As a result, they will feel more intrinsically invested, or engaged, in their decisions.

In practice, these principles should be utilized at every level in an organization — from senior leadership to managers to HR to coaches and wellness/disease management program staff to communications. When utilized to develop effective communication materials and health promotion programs, MI principles can help shape company culture to create a safer, more receptive environment for messages regarding behavioral change.

Health Belief Model (HBM): The Health Belief model6 was developed in the 1950s aspart of an effort by social psychologists in the U.S. Public Health Service to explain the lack of public participation in health screening and prevention programs. According to this model, changes in behavior depend on five factors:

Factor Characterized by the:

Perceived severity Belief that a health problem is serious

Perceived threatBelief that one is susceptible to the problem

Perceived benefitBelief that changing one’s behavior will reduce the threat

Perceived barriersPerception of the obstacles to changing one’s behavior

Self-efficiencyBelief that one has the ability to change one’s behavior

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Social Cognitive Theory: Social Cognitive Theory7 proposes that the environment, personal factors, and aspects of the behavior itself influence behavioral change. This theory explains the education process through a number of “constructs.” Those constructs that have applications in health education are:

1. Reinforcement — the positive or negative consequences of a behavior.

2. Behavior capability — in order for a change to take place, one must learn what to do to change and how to do it.

3. Expectancies — the value one places on the expected result. If the result is important to the person, the behavior change that will yield the result is more likely to happen.

4. Self-efficacy — belief in one’s ability to successfully change one’s behavior.

5. Outcome expectations — the benefits one expects to receive by changing one’s behavior.

6. Reciprocal determinism — the dynamic relationship between an individual and his or her environment.

Social cognitive theory not only explains how people acquire and maintain certain behavioral patterns, but it also provides a basis for intervention strategies.

Next we turn to a related field — still examining what goes on inside our heads — but now specifically focused on the mechanics of how we make decisions.

Discipline 2: Decision theoryUnquestionably, consumers need decision-making support, whether purchasing a car, booking a hotel, or selecting health care. Decision theory, the systematic study of how we arrive at certain conclusions or a course of action, provides several key insights that can add value when developing tools to effectively engage consumers8:

1. More information does not always improve decision making. In fact, frequently it undermines it. At first this may seem counter-intuitive, but research indicates that in the face of complex choices, people focus on familiar concepts or take mental shortcuts that reduce the cognitive effort required to make decisions. Often, we sacrifice thoroughness in favor of greater ease when making decisions.

2. Greater choice does not always improve decision-making. This also may seem surprising at first, but consider that as a bewildering array of choices floods our exhausted brains, there comes a point at which choice becomes debilitating rather than liberating.

3. Consumer preferences shift during the decision-making process. Not only the content, but the presentation of information can influence people’s perceptions about that information and their willingness to act upon it. Even unintentionally, the tools we provide may impact the outcome of decisions.

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4. Individuals use different modes of thinking – some analytical and some experiential – to make decisions. Health decisions are personal, interactive, urgent, dynamic, complex, and often made in times of personal crisis.

Two elements — risk and trust — interact to help shape decisions of all kinds. And these factors are particularly potent in health care decisions due to the complexity and the emotionally charged nature of many health care situations. Specifically, risk relates to the amount of personal risk involved in any specific decision, and trust relates to the level of confidence and reliance one places in the resources available to shape decision-making.

Often, we sacrifice thoroughness in favor of greater ease when making decisions.

For decisions where the trust is high and the risk is low, efficiency, cost and convenience become more important. When the risk increases and trust decreases, consumers tend to rely more on their social networks for decision support — which brings us to our third discipline.

Discipline 3: Social marketingSocial Marketing, frequently employed in branding and advertising, uses commercial marketing principles to motivate behavior changes that are beneficial to society at large. This is accomplished by identifying barriers to a desired behavior, and offering incentives to move toward the desired behavior by helping consumers perceive the benefits of doing so.

Many developers of health promotion campaigns have assumed that information is the key to getting consumers to perform a desired action. In the social marketing model, the emphasis is on changing perception. After focus groups and surveys determine why the consumer is not behaving as desired, a way to move toward that behavior that involves greater perceived benefits and fewer perceived barriers is developed. The key is to create an exchange where the perceived benefits of changing behavior outweigh the costs.

Where the trust is high and the risk is low, efficiency, cost, and convenience become more important.

Social Marketing theory also reinforces the importance of caregivers, friends/family, and support networks as critical target audiences since they have tremendous influence on decision-making. The key is determining how to engage these influencers. One of the most successful social marketing experiments was the Friends Don’t Let Friends Drive Drunk campaign. A 2002 Ad Council survey found that over 70 percent of Americans were aware of the campaign and 60 percent had taken action to prevent a friend or loved one from driving drunk.

Word of Mouth (WOM) marketing is another powerful social tool for evangelizing health tools and programs. WOM is an unpaid form of promotion in which satisfied individuals tell others how much they like a business, product or service. WOM has gained popularity in recent years with advertisers who have become convinced that consumers are more likely to listen to those they trust (influencers) than to claims made by advertisers. And this belief appears to be well founded — a recent study9 found that “recommendations from others” and

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even “consumer opinions posted online” significantly outranked TV, radio, print, and online advertising on the trust scale.

Employers can increase health promotion engagement by developing programs that not only engage consumers but also turn them into WOM marketers. For example, successful WOM about a workplace wellness challenge — such as a team-walking contest — could boost awareness and participation to create a company-wide cultural event.

Best practices in developing highly engaged health consumersThese theories and knowledge provide valuable insights that can be turned into actionable “best practices” for developing highly engaged health consumers. We recommend the following ten:

1. Focus on an “audience of one.” Consider employees’ underlying cultural differences, as well as personal values, attitudes, motivations, and behaviors when developing messages, tools, and programs. Help individuals develop accurate perceptions of their personal beliefs and health risks.

2. Recognize that health care decisions are emotionally charged and subject to manipulation. Education and decision-support tools must be sensitive to the potential emotions embedded in the process. For example, unlike most other decisions, the value of quality is likely to be higher in health care decisions than anywhere else.

3. Focus on benefits rather than features. Identify potential positive outcomes, promoting both intrinsic and extrinsic rewards.

4. Recognize that greater choice may not empower more confident decision-making. Seek to empower, not overwhelm. Focus on providing the information that is most relevant to the decision at hand. Use personal data and past experience to simplify choice (the “Amazon” model).

5. Understand how risk and trust shape decisions. Anticipate the trade-offs that employees will make as they weigh their choices. Enlist trusted advisors to help develop and deliver materials. Consider the level of trust embedded in your company’s culture, and in the sources of the information you provide.

6. Promote clear, actionable goal setting. Clearly identify concrete action plans with progressive, achievable steps. Seek to instill confidence and readiness.

7. Use peer pressure to your advantage. Don’t tolerate a culture of inertia or apathy toward your programs. Employ trusted role models to demonstrate desired behaviors. Stimulate WOM (word of mouth) to create a work environment with a “buzz” for healthy behaviors.

8. Extend engagement beyond the workplace. An employee’s home environment isnequally, if not more important, than workplace culture to support behavioral change. Engage spouses, children, and extended families through communications, education, empowerment, and rewards.

9. Keep it simple. Health care is very complex — the sheer number of providers, plan sponsors, program vendors, intermediaries and others that a consumer must navigate is daunting. Keep your messages simple to cut through the clutter.

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10. Don’t be afraid to have some fun! Remember, engagement is all about capturing attention. Having fun can help draw people in.

Employers can boost health promotion engagement by developing programs that not only engage consumers but also turn them into WOM marketers.

ConclusionBy gaining a deeper understanding of the complexities and challenges of behavioral change, employers can design programs that more effectively lead to lasting and meaningful lifestyle improvements, more cost-effective health programs, and a healthier, more productive workforce.

Let’s talkTo find out more contact us at 1 866 355 6647 or talktous@buck.com.

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©2018 Buck Global, LLC. All rights reserved.

References

1. Conduent HR Consulting Employer Health Care Strategy Survey, 2005.

2. Harris Interactive Health Care News Vol-ume 2 Issue 19 , October 11, 2002.

3. K Glanz and B.K Rimer. Theory at a Glance: A Guide for Health Promotion Prac-tice. National Cancer Institute.

Washington, D.C. 1995.

4. Prochaska, J. O. (1979). Systems of psychotherapy: A Transtheoretical analysis. Dorsey Press, Homewood, Illinois.

5. Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.

6. Becker, M.H. The Health Belief Model and Personal Health Behavior. Health Edu-cation Monographs. Vol. 2 No. 4, 1974.

7. Bandura, A. (1977). Social Learning Theo-ry. Englewood Cliffs, NJ: Prentice Hall.

8. Consumers in Health Care: The Burden of Choice. Prepared for California Health care Foundation, October 2005.

9. “What’s the Buzz on Word-of-Mouth Mar-keting?” Forrester Research, May 3, 2005

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